Accuracy of a simplified ecg-based algorithm (GUIDE algorithm) and added value of ecg imaging to achieve resynchronization in left bundle branch area pacing
M Regany, M Pujol-Lopez, R Borras, B Pellicer-Sendra, M Martinez-Perez, R Molero, F R Graterol, J Reventos-Presmanes, A Porta-Sanchez, I Roca-Luque, M S Guillem, A M Climent, E Guasch, J M Tolosana, L MontAbstract
Background
Several electrocardiographic (ECG) criteria have been proposed to confirm conduction system capture during left bundle branch area pacing (LBBAP), but their application remains complex. We previously reported a stepwise ECG algorithm (GUIDE) to simplify implantation and ensure ventricular resynchronization. Its validation was retrospective and limited to final lead position [1].
Objective
To prospectively evaluate the diagnostic performance of GUIDE algorithm to predict ventricular resynchronization and to analyze the added value of electrocardiographic imaging (ECGI), during LBBAP implantation.
Methods
Fifty-two patients undergoing LBBAP were included. ECGI ventricular activation maps were obtained as the lead was progressively advanced through the interventricular septum. Resynchronization was defined as a reduction of the left ventricular activation time (LVAT95) > 15ms. ECGs were assessed at each screwing stage and classified as GUIDE+ or GUIDE– (Figure 1).
Results
A total of 346 lead positions were analyzed (52 baseline, 194 GUIDE–, 100 GUIDE+). Progressive screwing reduced LVAT95: 76 ms at baseline, 65 ms in GUIDE– and 54 ms in GUIDE+ (p < 0.0001). The proportion of resynchronized positions increased from 49% in GUIDE– to 72% in GUIDE+ (p < 0.0001). The GUIDE algorithm showed 43% sensitivity, 78% specificity, 72% positive and 50% negative predictive value for ECGI-defined resynchronization.
Conclusions
GUIDE algorithm demonstrates high specificity but limited sensitivity in predicting ventricular resynchronization during LBBAP implantation. While GUIDE+ criteria indicate optimal resynchronization, some patients achieve resynchronization despite not meeting them. ECGI provides real-time assessment of ventricular activation and may complement decision-making in the clinical routine.ECG imaging mapping with GUIDE criteria